Provider Demographics
NPI:1669029542
Name:AHMAD MUSTAFFA, EZZA MELINA
Entity Type:Individual
Prefix:
First Name:EZZA MELINA
Middle Name:
Last Name:AHMAD MUSTAFFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 N PAULINA ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5093
Mailing Address - Country:US
Mailing Address - Phone:515-817-3828
Mailing Address - Fax:
Practice Address - Street 1:2045 W NORTH AVE STE 2B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5413
Practice Address - Country:US
Practice Address - Phone:773-249-2921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-24
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014078101Y00000X
IL180.015151101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor